No "Golden Hour" in Alaska: Characteristics and Implications of Medevac-centered Emergency Care

Rural areas in the United States have higher mortality rates than urban regions, particularly from emergency care-sensitive conditions. Air medical ambulances (medevacs) are critical to emergency care access in the rural U.S., but limited data hinder the ability to study this critical system. In Alaska, medevac services often represent the sole method for connecting Alaska Native patients in remote clinics to physician emergency medical care. This study characterizes medevac use and timing between tribally administered village clinics and hospitals in Northwest Alaska. Our objective in this study was to describe the use and timing of medevacs and investigate how medevac decision-making impacts medevac transport times.

We conducted a retrospective cohort analysis of medevac transfers between 2020-2024 from 11 Alaskan village clinics within the Maniilaq Association, which serves ~8,000 people over 35,862 square miles.We included 1,579 medevacs representing 1,119 unique patients flying from remote clinics to a central critical access hospital hub.. Our primary outcome measure was the association between short medevac decision times (< 60 minutes), and short total medevac times (< 180 minutes). We measured "flight time," "decision time," and "ground time" (time spent waiting for an aircraft to become available) as key components of total medevac time.

A total of 1,579 medevacs were deployed for predominantly Alaska Native (96.8%) patients, of whom 22.2% had traumatic injuries. Between 4.1-7.9% of community members in the region are transported by medevac each year. Median medevac time was 262 minutes (interquartile range [IQR] 196-402 [101-4,142]) from activation call to arrival at the critical access hospital. No medevacs were < 100 minutes. "Ground time" was the longest phase of medevac encounters overall (median ground time 105 minutes (IQR 81-187]) vs median decision time 75 minutes (IQR 42-130) or median flight time 44 minutes (IQR 35-77). We found no association between short medevac decision times and short medevac response time (P = .93). Medevac decision-making was the longest phase in only 6% of the shortest total medevacs (< 190 minutes), but it was the longest phase in 40% of the longest total medevacs ( > 400 minutes).

We found four key themes: 1) no medevacs were < 100 minutes. Independent of human or system factors,atients cannot be transferred from a village clinic to a critical access hospital within the "golden hour" of emergency care; 2) short medevac decision times were not significantly associated with short overall medevac times; 3) the longest phase in a medevac transfer was "ground time"; and 4) in the subset of the longest total medevacs, medevac decision-making was much more likely to be the longest phase than in the shortest total medevacs. This emergency transfer system is not responsive to patient condition and suggests that medevac decision support may help for a subset of encounters.